Complete Care at Phillipsburg, LLC

Inspectors wroteBased on observation, interview, and review of facility policy, it was determined that the facility failed to provide a homelike environment in resident rooms and common areas. The deficient practice was observed on 1 of 1 resident units during facility tour. The deficient practice was evidenced by the following: On 6/15/26 at 10:45 AM, during initial tour, the surveyor observed the following: 1. room [ROOM NUMBER] observed with multiple stained and buckled ceiling tiles. 2. room [ROOM NUMBER] observed with multiple stained and buckled ceiling tiles in the bathroom. 3. room [ROOM NUMBER] observed with multiple damaged floor tiles. 4. room [ROOM NUMBER] window track was observed dirty and had buckled ceiling tiles. 5. room [ROOM NUMBER] observed multiple stained ceiling tiles. 6. room [ROOM NUMBER] observed with multiple ceiling tile frames damaged and buckled ceiling tiles. 7. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to update and revise the comprehensive care plan of a resident. This deficient practice was identified for 3 of 15 residents reviewed, Resident #4, Resident #5 and Resident #12. The deficient practice is evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteRepeat DeficiencyBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain cleanliness of resident care equipment for 3 of 4 enteral feeding (TF) residents (Resident #3, #4, and #36) and b.) maintain infection control standards and procedures during wound care for 1 of 1 resident (Resident #31). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to dependent residents in a timely manner for 2 of 3 residents (Residents #25 and #52) observed for incontinence care on 1 of 1 Nursing unit. This deficient practice was evidenced by the following: On 6/16/26 at 8:15 AM, the surveyor conducted an incontinence care tour on the Nursing Unit and observed the following:1. On 6/16/26 at 8:15 AM, the surveyor, accompanied by the Certified Nursing Assistant (CNA #1), observed Resident #25 in bed. CNA #1 exposed Resident #25's incontinence brief and observed that the brief was saturated with urine. CNA #1 confirmed that the brief was saturated and stated that incontinence care should be done every 2 hours. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined the facility failed to a.) maintain the required minimum direct care staff-to-resident ratios as mandated by the State of New Jersey, and b.) failed to ensure that sufficient and competent staff were available to provide appropriate incontinence care to dependent residents for 2 of 3 residents (Resident #25 and #52) on 1 of 1 Nursing Unit. This deficient practice was evidenced by the following: Refer to F677 Reference: New Jersey Department of Health (NJDOH) memo, dated 01/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility policies it was determined that the Consultant Pharmacist (CP) failed to clarify medication route for a resident during the monthly medication reviews for 1 of 4 Residents, (Resident #36). This deficient practice was evidenced by: 1. On 6/15/26 at 10:51 AM, the surveyor observed Resident 36's enteral feeding machine (TF, medical devices designed to safely deliver nutrition directly into the gastrointestinal tract) in their room. On 6/15/26 at 11:20 AM, the surveyor reviewed the electronic medical record (E-mar) for Resident #36. A review of the resident's admission record (AR, an admission summary) revealed the resident was admitted to the facility with diagnoses that included but were not limited to; [...]

Inspectors wroteBased on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication, by failure to correctly document a diagnosis, indication, or reason for use for one (1) of five (5) residents reviewed for unnecessary medication (Resident #12). The deficient practice was evidenced by the following: On 6/22/26 at 12:00 PM, the surveyor reviewed Resident #12's electronic medical record (EMR) which revealed the following: An admission Record (AR)(a summary of admission documents), that reflected that Resident #12 was admitted to the facility with medical diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure kitchen staff properly air-dried pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 49 of 51 residents who resided in the facility and who received dietary services. There were two residents receiving tube feedings. The facility had a census of 51 residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one out of one resident (Resident (R) 42) reviewed for Pre-admission Screening and Resident Review (PASRR) had accurate screenings and/or were referred for a Level II review as required following a positive Level I screening. This had the potential to cause delays in receiving necessary mental health services. Total sample was 23. Findings Include: Review of the facility Preadmission Screening and Resident Review (PASARR) policy updated on 07/01/24, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include a. [...]

Inspectors wroteBased on observations, record review, interviews, and review of facility policies, the facility failed to ensure a respiratory assessment was completed prior to initiating a breathing treatment and failed to monitor the resident's respiratory condition, including response to therapy provided, and any changes in the respiratory condition during the breathing treatment. This involved one of 28 sampled residents (Resident (R) 29).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure a catheter bag was kept off the floor for one of one resident (Resident (R) 48) reviewed for catheters in a total sample of 23 residents. The failure to keep a catheter bag off the floor increased the risk for R48 developing a urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to date medication when opened and stored for continued use. This was found in 2 of 3 medication carts and 1 of 1 medication refrigerator. The deficient practice was evidenced by the following: On [DATE] at 9:35 AM, the surveyor inspected the annex medication cart with Licensed Practical Nurse #1 (LPN #1). Inside of the annex medication cart there was one vial of Humalog insulin that was open and dated [DATE] and one vial of Humalog insulin that was open and dated 9/20. LPN # 1 confirmed the dates then took them and said they were out dated and he didn't know why they were in the medication cart. According to manufacturer specifications Humalog insulin should be discarded 28 days after opening. [...]

Inspectors wroteBased on observation, interview and policy review it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was evidenced by the following: On 12/19/22 at 9:15 AM, in the presence of the Food Service Manager (FSM) and the Regional Food Service Director (RFSD), the surveyor observed the following: 1. In the food preparation area, the surveyor observed grey colored material stuck on the blade of the can opener. 2. On a shelf in the Cook's refrigerator, the surveyor observed a container of cranberry sauce, which had a written date in marker of 11/16/21 and a stamped manufacturer expiration date of 7/23/22. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to clean and disinfect three of three shower chairs observed in the shower room. This deficient practice was as evidenced by the following: On 12/22/22 at 10:40 AM, the surveyor interviewed five residents during a resident council meeting. At the end of the resident council meeting, the surveyor asked the residents if they had any other concerns and two of five residents stated that the shower chairs in the shower room were not clean and that the shower chairs had black and brown substances on them. On 12/22/22 at 12:15 PM, the surveyor went into the shower room and observed three shower chairs stored inside the room. [...]